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Fat Taxes and the Nanny State

Two reports published today make recommendations about the way in which obesity should be treated in the UK. These two reports, Public Health: Ethical Issues produced by the Nuffield Council on Bioethics and British Fertility Society’s guidelines on the effect of obesity on female reproductive health both contain important analysis of the role of the state in dealing with the problem of obesity. The Nuffield Council Report also considers smoking, alcohol consumption, infectious disease control and the fluoridisation of water.

There are at least two kinds of things that can be said about the role of the state in public health issues like obesity, smoking or excessive alcohol consumption. First, there is the thought that people are entitled to live their lives in the way that they see fit – in a way that best coheres with what they take to be meaningful and valuable. With this freedom, however, comes a responsibility for the decisions that one makes. Justice requires that the government should provide for those who are disadvantaged by their situation — those who, through no fault of their own, are poor or sick or without the necessities of life. In the normal course of events people just get sick and it is the business of government to provide for these people. This provision, however, does not extend to those who are sick through their own fault or through the particular lifestyle choices that they have made. The state should protect people from the ‘ravages’ of circumstance not from the consequences of choice. When someone freely chooses to live life in a particular way, he, not society must, at some point, shoulder the responsibility for those choices.

A second relevant argument here is somewhat out of fashion in contemporary society — it is a paternalistic one. It takes a stronger line on the justifiability of choices that are ‘unhealthy.’ We know that smoking is bad for people and we know that smokers are more likely to die early and unpleasantly. Given this there is no good reason why people should smoke: it is undoubtedly the case that smokers would be better off if they did not smoke, that heavy drinkers would be better off if they did not drink heavily.

There will be some difficult cases in determining which kinds of conditions and the degree of excess but this does not prevent there from being some cases that are clear: a pack-a-day smoking habit looks to be one. This is not the beginning of a slippery slope. There is a clear evidential basis for this and the ‘restrictions’ could be applied on strictly defined criteria.

Of course there are various steps that society might take to prevent people engaging in these dangerous activities. Education, perhaps aggressive and targeted, would be a key component, as might taxation of various kinds. But perhaps a very effective driver of change would be to combine education with ‘treatment.’ Mandatory attendance at smoking cessation classes, personal targets and progress assessments might all be used to change the way in which those who continue to choose the unhealthy option have access to health care. This does not represent a strong form of restriction of access but it does represent a strong condemnation of these practices translated into action steps.

Perhaps the main difficultly with the arguments about choice and responsibility is determining whether the choices in question are actually freely made. The obvious obstructions to free choice are addiction and genetics: once a person is addicted it no longer is a simple matter of free choice; similarly there may be some for whom addiction or certain kinds of choices are heavily influenced by genetics. However there are broader influences that might be at work here. Socio-economic status, education and social support networks are all correlated with poor health outcomes and with such ‘lifestyle’ choices as heavy smoking, heavy drinking and obesity. So someone who is raised in a context in which those around them smoke and drink heavily and who live in a community where these activities are acceptable or the norm is likely (or more likely) to smoke and drink.

It is not enough to insist that people still have a choice — ‘they can still stand on their own two feet.’ Although this is true it does not alter the fact that the biases and influences that confront people in their choices and indeed the formation of their values and identity are endorsed or at least permitted by the communities and society to which they belong. So while individual choice and responsibility are certainly relevant considerations, the matter is far from simple and the attribution of blame is far from straightforward.

The Nuffield Council Report describes a model for the approach that governments should take in public health generally. They call this the ‘Stewardship model’:

This model recognises that the state should not coerce people or restrict their freedoms unnecessarily, but also that the state has a responsibility to provide the conditions under which people can lead healthy lives if they wish.

This model is certainly on the right track but it is not clear that it goes far enough. If the full story about the way in which obesity and ill-health are related to socio-economic status is correct then much more needs to be done to manage social forces than the initial recommendations of the Nuffield Council of Bioethics allow.

In all of this, the Nuffield Council Report is correct to remind us that the steps taken should be managed carefully to avoid increased stigmatisation. Recognising that people have a responsibility is distinct from the business of blame. The fat tax for airline travel proposed in Australia falls foul of this idea. Using air travel to highlight the obesity problem is entirely about coercion through blame.

On the other hand, the British Fertility Society guidelines do not blame. Instead they restrict access for the benefit of the pregnant woman, her child and to facilitate the efficient use of the resources.

Fertility Report 

Nuffield Report 

Fat tax on airline travel:

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